Letter to the Editor

An Unusual Case of Nonhealing Leg Ulcer in a Diabetic Patient

Authors: Sagar U. Nigwekar, MD

Abstract

To the Editor:


A 49-year-old woman was hospitalized for a nonresolving left leg ulcer. The patient had a history of uncontrolled type 2 diabetes mellitus, and was evaluated by vascular surgery, who believed that the ulcer was a complication of uncontrolled diabetes. Physical examination was positive for an extremely tender, oval, violaceous ulcer measuring 8 × 5 cm with surrounding cellulitic changes. Laboratory workup revealed leucocytosis, a normal serum creatinine, elevated glycosylated hemoglobin of 9.5% (4.6–6.0%) and elevated corrected serum calcium of 11.2 (8.5–10.2 mg/dL). Magnetic resonance imaging of the left leg showed no osteomyelitis. The patient was started on a local wound care program and antibiotic coverage with no significant improvement. Further evaluation showed a serum phosphorous level of 2.1 mg/dL (2.2–4.5 mg/dL); intact parathyroid hormone, 82 pg/mL (14.0–72.0 pg/mL); and a normal 1,25 dihydroxy vitamin D3 concentration. She continued to have severe leg pain with intermittent fevers and a full-thickness skin biopsy was performed. Histologic examination revealed widespread septal panniculitis and calcifications in the adventitia of the small and medium-sized vessels with luminal narrowing, consistent with calciphylaxis. The patient subsequently underwent a parathyroid exploration that showed a left inferior gland adenoma weighing 0.6 g, for which a parathyroidectomy was performed. These findings were consistent with the diagnosis of primary hyperparathyroidism. Following parathyroidectomy, the serum calcium level returned to normal and near complete resolution of the leg ulcer was achieved.

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